Schema therapy for violent PD offenders: a randomized clinical trial

Authors David P. Bernstein, Marije Keulen-de Vos, Maartje Clercx, Vivienne de Vogel, Gertruda Kersten, Marike Lancel, Stefan Bogaerts, Mariëtte Slaats, Nick Broers, Thomas Deenen, Arnoud Arntz
Published in Psychological Medicine
Publication date 15 March 2021
Research groups Working with Mandated Clients
Type Article


Background. Violent criminal offenders with personality disorders (PD’s) can cause immense harm, but are often deemed untreatable. This study aimed to conduct a randomized clinical trial to test the effectiveness of long-term psychotherapy for rehabilitating offenders with PDs. Methods. We compared schema therapy (ST), an evidence-based psychotherapy for PDs, to treatment-as-usual (TAU) at eight high-security forensic hospitals in the Netherlands. Patients in both conditions received multiple treatment modalities and differed only in the individual, study-specific therapy they received. One-hundred-three male offenders with antisocial, narcissistic, borderline, or paranoid PDs, or Cluster B PD-not-otherwise specified, were assigned to 3 years of ST or TAU and assessed every 6 months. Primary outcomes were rehabilitation, involving gradual reintegration into the community, and PD symptoms. Results. Patients in both conditions showed moderate to large improvements in outcomes. ST was superior to TAU on both primary outcomes – rehabilitation (i.e. attaining supervised and unsupervised leave) and PD symptoms – and six of nine secondary outcomes, with small to moderate advantages over TAU. ST patients moved more rapidly through rehabilitation (supervised leave, treatment*time: F(5308) = 9.40, p < 0.001; unsupervised leave, treatment*- time: F(5472) = 3.45, p = 0.004), and showed faster improvements on PD scales (treatment*- time: t(1387) = −2.85, p = 0.005). Conclusions. These findings contradict pessimistic views on the treatability of violent offenders with PDs, and support the effectiveness of long-term psychotherapy for rehabilitating these patients, facilitating their re-entry into the community

On this publication contributed

Language English
Published in Psychological Medicine
Key words Schema Therapy, psychotherapy, treatment, forensic, Antisocial Personality Disorder, personality disorders, psychopathy, violence, aggression, rehabilitation, recidivism, randomized clinical trial, treatment outcomes
Digital Object Identifier 10.1017/S0033291721001161
Page range 1-15